Prevalence of diagnosed depression, anxiety, and ADHD among youth with type 1 or type 2 diabetes mellitus

Abstract

We examined the prevalence of diagnosed depression, anxiety, and ADHD among youth by diabetes type, insurance type, and race/ethnicity. These mental disorders were more prevalent among youth with diabetes, particularly those with type 2 diabetes, with non-Hispanic White youth with Medicaid and diabetes having a higher prevalence than other races/ethnicities.

1. Introduction

The incidence of diabetes in U.S. youth has increased over the past two decades, affecting approximately 283,000 individuals in 2019 [1,2]. Diabetes in youth is associated with an increased risk of mental disorders [3,4], which can negatively impact diabetes management [5,6]. Previous studies primarily focused on depression [3–5], did not distinguish between diabetes type [7], were based on self-reported diagnosis [7,8], or were conducted outside the U.S. [9,10]. Moreover, despite persistent disparities in mental health status and use of care [7,11,12], little is known about the role of insurance type and race/ethnicity in the associations of diabetes type and mental disorders, particularly anxiety and attention-deficit/hyperactivity disorder (ADHD), in youth. Using administrative claims databases, we examined the prevalence of diagnosed depression, anxiety, and ADHD in youth aged 2–17 years with type 1 (T1DM) or type 2 diabetes mellitus (T2DM) by insurance type and race/ethnicity.

2. Methods

We included 3,101,426 youth aged 2–17 years with Medicaid and 3,564,727 youth with private insurance, from the 2019 MarketScan^® Database. We included those continuously enrolled in 2019 with mental health and substance abuse coverage and prescription drug coverage. Diabetes type and mental disorders were identified using published criteria (Appendix 1) [13,14]. Age- and sex-adjusted prevalence and adjusted prevalence ratios (aPR) were estimated using multivariable logistic regression with predictive margins. Prevalence was stratified by race/ethnicity only for Medicaid enrollees due to the lack of information for those with private insurance. To consider the possibility of misdiagnoses of mental disorders or T2DM in children aged < 10 years, sensitivity analyses were performed restricting to ages 10–17 years. Analyses were performed using Stata 17.

3. Results

Youth with diabetes mellitus (DM) were older than those without DM; youth with T2DM were more likely to be female than those with T1DM or no DM (Appendix 2). Among Medicaid enrollees, youth with T2DM were more likely to be non-Hispanic Black (NHB), while those with T1DM or no DM were more likely to be non-Hispanic White (NHW).

Compared to youth without DM, those with DM had a higher prevalence of mental disorders, ranging from 20 % higher prevalence of ADHD among youth with T1DM to > 200 % higher prevalence of depression among those with T2DM (Fig. 1). Compared to youth with T1DM, those with T2DM had a higher prevalence of all three mental disorders. Prevalence ratios of individual disorders were similar across insurance type, except depression for youth with T1DM (aPR 2.2 for Medicaid vs. 1.8 for private insurance). Regardless of insurance type, prevalence of comorbid mental disorders (i.e., more than one of the three selected disorders) was highest among those with T2DM (7.6–7.8 %), followed by those with T1DM (4.4–4.5 %) and those without DM (2.4–2.6 %). Sensitivity analyses revealed similar patterns; prevalence ratios were similar, although mental disorder prevalence was higher among those aged 10–17 years for all groups (Appendix 3).

Fig. 1.

Age- and sex-adjusted prevalence ratios for selected mental disorders (depression, anxiety, and ADHD) among youth aged 2–17 years with Medicaid or private insurance, by diabetes status, 2019 Merative^® MarketScan^® data ^a Total sample size was 3,101,426 for the Medicaid group, including 5001 youth with T1DM, 1784 youth with T2DM, and 3,094,641 youth without diabetes.^b Total sample size was 3,564,727 for the private insurance group, including 9319 youth with T1DM, 1213 youth with T2DM, and 3,554,195 youth without diabetes mellitus.^c Comorbid mental disorders indicate the prevalence of those with more than one of the three selected mental disorders. Prevalence ratios were estimated compared to those without diabetes mellitus (no DM). Significant differences across the groups were based on non-overlapping 95 % CIs. T1DM, type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus; DM, diabetes mellitus; ADHD, attention-deficit/hyperactivity disorder; CI, confidence interval; aPR, adjusted prevalence ratio.

Among Medicaid enrollees with T1DM, NHW youth had a higher prevalence of anxiety and ADHD than NHB youth and a higher prevalence of ADHD than Hispanic youth (Table). Among Medicaid enrollees with T2DM, NHW youth had a higher prevalence of depression and anxiety than NHB youth and a higher prevalence of anxiety and ADHD than Hispanic youth. Sensitivity analyses showed consistent results (Appendix 4).

Table 1.

Age- and sex-adjusted prevalence of selected mental disorders (depression, anxiety, and ADHD) among youth aged 2–17 years with type 1 or type 2 diabetes mellitus and Medicaid insurance ^a by race/ethnicity, 2019 Merative^® MarketScan^® data.

	T1DM (n = 5001)			T2DM (n = 1784)
	n	%	95 % CI (%)	n	%	95 % CI (%)
	Depression	445			315
By race/ethnicityb
NHW	275	9.4 %	[8.4, 10.4]	132	22.3 %	[19.0, 25.6]
NHB	110	7.9 %	[6.5, 9.3]	130	14.8 % *	[12.5, 17.1]
Hispanic	25	10.5 %	[6.7, 14.3]	25	15.4 %	[9.9, 20.9]
Others	17	12.0 %	[6.8, 17.3]	12	19.9 %	[9.9, 29.9]
Anxiety	394			241
By race/ethnicityb
NHW	267	9.1 %	[8.1, 10.1]	124	20.7 %	[17.4, 23.9]
NHB	76	5.5 %*	[4.3, 6.7]	75	8.6 %*	[6.7, 10.5]
Hispanic	24	10.1 %	[6.3, 13.9]	20	12.3 % *	[7.3, 17.3]
Others	11	7.8 %	[3.4, 12.2]	9	NRc	NRc
ADHD	658			386
By race/ethnicityb
NHW	426	14.1 %	[12.9, 15.4]	137	22.1 %	[18.9, 25.3]
NHB	154	11.6 % *	[9.9, 13.3]	197	23.3 %	[20.5, 26.1]
Hispanic	18	7.8 %*	[4.3, 11.2]	16	9.5 %*	[5.1, 13.9]
Others	12	9.3 %	[4.4, 14.3]	11	18.5 %	[8.7, 28.3]
Comorbidd	326			236
By race/ethnicityb
NHW	226	7.7 %	[6.7, 8.6]	114	19.0 %	[15.9, 22.1]
NHB	73	5.3 %*	[4.1, 6.4]	96	11.0 % *	[8.9, 13.1]
Hispanic	17	7.2 %	[3.9, 10.4]	16	9.8 %*	[5.3, 14.4]
Others	10	7.2 %	[3.0, 11.5]	10	16.6 %	[7.2, 26.0]

^*Significantly different from the reference group (NHW) at P < 0.05 based on multivariable logistic regressions. T1DM, type 1 diabetes mellitus; T2DM, type 2 diabetes mellitus; NHW, non-Hispanic White; NHB, non-Hispanic Black; ADHD, attention-deficit/hyperactivity disorder; CI, confidence interval; NR, not reported.

^aRace/ethnicity data was not available in the private insurance database.

^bThose with missing information on race/ethnicity (6 % of Medicaid youth

^cEstimates are not reported due to small sample size and relative standard error (RSE) above 30 %. RSE was calculated for all the estimates as the standard error divided by the estimate and multiplied by 100.

^dComorbid mental disorders indicate the prevalence of those with more than one of the three selected mental disorders.

4. Discussion

Youth with DM had a significantly higher prevalence of depression, anxiety, and ADHD than those without DM, with 90–240 % and 20–120 % higher prevalence in youth with T2DM and T1DM, respectively. Additionally, this study highlights a significantly higher prevalence of mental disorders among youth with T2DM than T1DM, regardless of insurance type. This is consistent with previous findings of more depression among adolescents with T2DM than T1DM [5], now extended to anxiety and ADHD. The greater association of T2DM with mental disorders may be partly attributed to their lower household income than youth with T1DM [5,15]. In addition, this may be associated with other common risk factors for mental disorders, including the youth’s health status such as obesity, caregiver education, or urbanicity of residence [11,15].

Our analyses by race/ethnicity among Medicaid youth with DM found that mental disorders were generally more prevalent among NHW youth than NHB or Hispanic youth, with the difference varying by diabetes type. The findings for youth with T2DM (i.e., the prevalence of anxiety was highest among NHW youth and highest for ADHD among NHW or NHB youth) were similar to a previous study of youth in general [11], while youth with T1DM showed slightly different results; the prevalence of anxiety and ADHD were highest only among NHW youth. Our finding of more depression among NHW youth with T2DM than NHB youth was not consistent with a previous study of youth with T2DM that reported depressive symptoms were not associated with race/ethnicity [3]. The difference may be partly due to differences in outcome measures (diagnosed depression vs. self-reported depressive symptom), study populations (youth with Medicaid vs. youth with any payors), and study periods (2019 vs. 2009–2011) between two studies.

Limitations of our analysis include a cross-sectional design that lacks information on duration of diagnoses; a sample population that may not be representative of the overall Medicaid or general US youth population but may be generalizable to US youth with private health insurance; and an inability to assess unmet mental health care needs, misdiagnoses of diabetes type and mental disorders, or missed diagnoses.

Our study adds to the literature by providing estimates of the prevalence in youth with DM of the most common mental disorders among youth using claims data. We found significant differences in mental disorder prevalence by diabetes type and race/ethnicity, highlighting the need for improved health care for this population [16]. In addition to recommended depression and anxiety screening, our results suggest the potential utility of screening for ADHD among youth with DM in primary care settings. Future studies may be needed to examine factors contributing to these differences and inform screening, diagnosis, and treatment approaches for mental health in youth with DM. Given the negative impact of mental disorders on diabetes management [5], our findings underscore the importance of routine monitoring, appropriate treatment, and coordinated care for mental disorders in youth with DM [16].